CASE REPORT ndash OPEN ACCESSInternational Journal of Surgery Case Reports 7 (2015) 119ndash123
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports
journa l homepage wwwcaserepor ts com
Splenic metastasis from gastric adenocarcinoma A rare case
Marco Santos lowast Vilma Martins Filipa Moreno J Ramoacuten Vizcaiacuteno Isabel MesquitaCentro Hospital do Porto ndash Hospital de Santo Antoacutenio Largo Prof Abel Salazar 4099-001 Porto Portugal
a r t i c l e i n f o
Article historyReceived 24 July 2014Received in revised form 31 August 2014Accepted 29 October 2014Available online 5 November 2014
INTRODUCTION Isolated splenic metastasis are very rare There are only a few reported cases of patientswith isolated splenic metastasis from gastric primary tumorsPRESENTATION OF CASE We present a case of a 71-year-old patient with isolated splenic metastasis diag-nosed 6 years after primary treatment of a gastric adenocarcinoma who previously had a lung resectionalso for metastasis The patient was submitted to chemotherapy and then to splenectomy The patient isalive and has no evidence of disease 7 months after splenectomyDISCUSSION We discuss the theories that explain the rare event of splenic metastasis the route of metas-tization the workup treatment and survival of patients with isolated splenic metastasis To the best ofour knowledge our case has the second longest interval from the primary diagnosis of gastric cancer tothe diagnosis of splenic metastasisCONCLUSION In cases of isolated splenic metastasis from gastric adenocarcinoma fit patients should beconsidered for splenectomy since there are reports of good patient survivals
copy 2014 The Authors Published by Elsevier Ltd on behalf of Surgical Associates Ltd This is an openaccess article under the CC BY-NC-ND license (httpcreativecommonsorglicensesby-nc-nd30)
1 Introduction
Splenic metastasis are uncommon1ndash4 The largest studies onautopsy reports from patients with non-haematogenous tumorsstated a 03ndash73 rate of splenic metastasis2 In most cases thishappens as part of disseminated multi-organ disease
The most frequent primary tumors metastasizing to the spleenare breast lung ovary colorectal skin and gastric1ndash35 The latterare reported with an incidence of 692
Isolated splenic metastasis are very rare with only a fewreported cases of patients with primary gastric tumors6
The authors present a case of a patient with isolated splenicmetastasis from primary gastric adenocarcinoma
2 Presentation of case
A 71-year-old man underwent a total gastrectomy with D2lymphadenectomy and Y-Roux reconstruction for a distal smallcurvature gastric cancer in 2005 Histologic report confirmed awell differentiated adenocarcinoma Laurensrsquos intestinal type and28 non-metastasized lymph nodes ndash final staging pT3N0M0 He wasnot proposed to chemotherapy
After 6 years of follow-up it was noted an elevated CA199 withnormal CEA (Graphic 1 ndash June2011) Computerized tomography
lowast Corresponding author at Rua Satildeo Tomeacute e Principe nr 376 hab 33 4430-228Vila Nova de Gaia Portugal Tel +351 962624399
E-mail address msilvasantosgmailcom (M Santos)
(CT) scan revealed an isolated nodular lesion on the left superiorlobe of the lung (Fig 1) After two attempts of percutaneous biopsy(both yielded insufficient tissue) it was decided to proceed withsurgical excision On December2011 he was submitted to a leftsuperior lobectomy Histology confirmed a gastric adenocarcinomametastasis with complete excision
Three months after the pulmonary surgery the patient pre-sented an even greater rise of CA199 (Graphic 1 ndash March2012)CT scan showed a splenic formation with undetermined mean-ing At this point it was decided to perform a positron emissiontomographyndashcomputed tomography (PETndashCT) scan which revealedtwo active spots ndash one on the left lung related to the previ-ous surgery (a false-positive) and the other one on the spleen(Fig 2)78 On Oncology Group (OG) discussion these findings were
Graphic 1 Tumoral markers evolution since Jan2010 6 years after the primarygastric surgery
httpdxdoiorg101016jijscr2014100942210-2612copy 2014 The Authors Published by Elsevier Ltd on behalf of Surgical Associates Ltd This is an open access article under the CC BY-NC-ND license(httpcreativecommonsorglicensesby-nc-nd30)
CASE REPORT ndash OPEN ACCESS120 M Santos et al International Journal of Surgery Case Reports 7 (2015) 119ndash123
Fig 1 Image of CT scan showing a pulmonary nodule with 28 times 19 mm speculatedand irregular suspected of metastasis
interpreted as disseminated disease and it was proposed palliativechemotherapy
After 6 cycles of epirubicin oxaliplatin and capecitabine (EOX)which terminated on October2012 CA199 normalized and thepatient remained asymptomatic The OG decided to keep a sup-portive treatment
On April2013 the patient had another CA 199 elevation withan 18 mm splenic lesion on CT scan compatible with previouslydiagnosed metastasis
On August2013 the patient remained asymptomatic althoughthe splenic lesion grew to 25 mm (Fig 3) with no evidence of othermetastasis
The apparently indolent evolution of the disease and the goodphysiologic status of the patient promoted the OG decision to per-form splenectomy
The surgery was performed on the 21November2013 Intra-operatively it was seen a hard nodule on the inferior pole of the
spleen with extension to the hilum No other lesions were notedThe post-operative period was uneventful and the patient was dis-charged at the 4th day after surgery
The pathological examination confirmed the presence of a25 times 15 times 10 mm nodule with hilar and capsule invasion withhistological morphology of an adenocarcinoma After immuno-histochemical study and pathological comparative review of theprimary carcinoma the lesion was deemed most likely to be a gas-tric adenocarcinoma metastasis (Figs 4 and 5) There were twoother metastatic nodules with 15 and 10 mm located in the splenicparenchyma independent from the first nodule and with no cap-sule invasion
Again he was proposed chemotherapy with EOXAt present the patient is receiving chemotherapy with very
good tolerance and has no evidence of disease
3 Discussion
From the early 20th century there have been explanations stat-ing that there are obstacles preventing tumoral cells from reachingthe spleen These include the sharp angle of the splenic artery withthe celiac trunk and the rhythmic contraction of splenic sinusoidalsAs we know from present knowledge the success of metastizationseems to be much more dependent on the local microenvironmenton which the tumoral cells lodge and the interactions betweenthem9 The spleen seems to be hostile to the growing of clinicalmetastasis probably related to its immune function For 6 yearsour patient had ldquodormantrdquo cells or micrometastasis that suddenlystarted to grow To the best of our knowledge our case has the sec-ond longest interval from the primary diagnosis of gastric cancerto the diagnosis of splenic metastasis610
The usual suggested route of metastization is hematogeneousrelated to parenchymal location of the metastasis and no capsuleinvasion On our case there were two small parenchymal metasta-sis with no capsule invasion but the biggest metastasis had capsule
Fig 2 Image of PET-CT showing a splenic hot spot suspect of metastasis
CASE REPORT ndash OPEN ACCESSM Santos et al International Journal of Surgery Case Reports 7 (2015) 119ndash123 121
Fig 3 Image of CT scan showing a 25 mm splenic lesion near its inferior pole compatible with metastasis
Fig 4 HampE 40times and 100times ndash moderately differentiated adenocarcinoma infiltrating the splenic parenchyma and inducing a mild desmoplastic and inflammatory reaction
Fig 5 CK 7 and CK 20 400times ndash immunohistochemical studies for cytokeratins 7 and 20 showed expression of cytokeratin 7 and no expression of cytokeratin 20 Thisimmunoprofile is coincident with the primary gastric tumor profile suggesting the gastric origin of this metastasis
CASE REPORT ndash OPEN ACCESS122 M Santos et al International Journal of Surgery Case Reports 7 (2015) 119ndash123
invasion Despite this the hematogeneous route is the most prob-able since there were no lymph nodes involved at the primarysurgery and there was no peritoneal seeding
Some reported cases of isolated splenic metastasis seem to bepart of aggressive loco-regional advanced disease with great prob-ability of being a fully disseminated disease not recognized at thatpoint These cases are mostly seen on upper third gastric tumorslocally advanced tumors with extensive nodal involvement andinvariably short survival6
Most patients are asymptomatic The symptoms and signs mostfrequently reported are asthenia weight loss abdominal painanemia and splenomegaly4 There are cases of splenic abscess for-mation or rupture as initial presentation211
Most diagnosis are dependent on imaging Ultrasound and CTscan are the usual performed exams during follow-up wheneverindicated by symptoms or elevation of CEA and CA 19912 At someinstances there is doubt about the nature of lesions PET-CT scanmight be very useful since it has a high negative predictive valueconsidering malignant lesions and it might show other probablemetastatic spots not detected on CT scan78
A true pre-operative diagnosis of splenic metastasis can only bemade through biopsy Although it is rarely described it is consid-ered both safe and reliable when evaluating splenic lesions1314 Ourpatient was not submitted to biopsy since there was a good corre-lation between CT and PET-CT scan suspicion lesion evolution andtumoral markers The diagnosis of metastasis was highly probableWe recommend biopsy on less clear cases
On reported cases of isolated splenic metastasis as long as thepatients are fit they get treated by splenectomy with or withoutchemotherapy61215
Chemotherapy varies from neoadjuvant to adjuvant settingsmultidrug or monodrug regimens There are not consensual pro-tocols Our patient had multidrug chemotherapy with EOX whichare first line drugs on National Comprehensive Cancer Networkguidelines
Our case is remarkable because our patient had a resected pul-monary metastasis prior to the splenic metastasis diagnosis Thehigh probability of having multi-organ disseminated disease wasthe rationale for the decision to perform palliative chemother-apy and then supportive treatment only With time the patientproved he was a great candidate for surgery since no other metas-tasis grew This ldquowait-and-seerdquo approach has been defended as away of selecting patients that truly benefit from aggressive surgicaltreatment615 Overall the reported cases do not mention relevantcomplications from splenectomy in this setting
The reported overall survivals point an advantage if the metas-tasis are diagnosed within a medium to long follow-up Patientswho had long free disease survivals are also the ones with longestoverall survival610
4 Conclusion
In cases of isolated splenic metastasis from gastric adenocar-cinoma fit patients should be considered for splenectomy sincethere are reports of good patient survivals3610
Conflict of interest
None
Funding
None
Ethical approval
Written informed consent was obtained from the patient forpublication of this case report and accompanying images A copyof the written consent is available for review by the Editor-in-Chiefof this journal on request
Author contributions
Marco Santos design of article research manuscript revi-sion and approval Vilma Martins second surgeon designresearch revision and approval Filipa Moreno pathologicalreport photographs design revision and approval J Ramoacuten Viz-caiacuteno pathological report analysis revision and approval IsabelMesquita first surgeon and patient assistant conception anddesign of article consultant manuscript revisor final revision andapproval
Authorship
The authors claim full responsibility for the production ofthis article and state that they have seen and approve the finalmanuscript being submitted The authors declare their agreementregarding Publication Rules in International Journal of Surgery CaseReports
Key learning points
bull Splenic metastasis are rarebull Surgery should be considered for selected patients as a way of improving survival
References
1 Soares FA Herbst CRIG Metaacutestases esplecircnicas em neoplasias soacutelidas Acta OncolBras 19882(8)52ndash4
2 Lam KY Tang V Metastatic tumors to the spleen a 25-year clinicopatho-logic study Arch Pathol Lab Med 2000124(4)526ndash30 httpdxdoiorg1010430003-9985 124lt0526MTTTSgt20CO2
3 Compeacuterat E Bardier-Dupas A Camparo P Capron F Charlotte F Splenicmetastases clinicopathologic presentation differential diagnosis and patho-genesis Arch Pathol Lab Med 2007131(6)965ndash9 httpdxdoiorg1010431543-2165131[965SMCPDD]20CO2
4 Showalter SL Hager E Yeo CJ Metastatic disease to the pancreas and spleenSemin Oncol 200835(2)160ndash71
5 Agha-Mohammadi S Calne RY Solitary splenic metastasis case report andreview of the literature Am J Clin Oncol 200124306ndash10 httpdxdoiorg10109700000421-200106000-00020
6 Zhu Y Mou Y Ni J Zhou Y Jiang J Jiang Z et al Isolated splenic metastasesfrom gastric carcinoma a case report and literature review World J Gastroenterol201319(31)5199ndash203 httpdxdoiorg103748wjgv19i315199
7 Long NM Smith CS Causes and imaging features of false positives and falsenegatives on F-PETCT in oncologic imaging Insights Imaging 20112(6)679ndash98httpdxdoiorg101007s13244-010-0062-3
CASE REPORT ndash OPEN ACCESSM Santos et al International Journal of Surgery Case Reports 7 (2015) 119ndash123 123
8 Metser U Even-Sapir E The role of 18F-FDG PETCT in the evaluation ofsolid splenic masses Semin Ultrasound CT MRI J Nucl Med 200627(5)420ndash5
9 Chambers AF Groom AC MacDonald IC Dissemination and growthof cancer cells in metastatic sites Nat Rev Cancer 20022(8)563ndash72httpdxdoiorg101038nrc865
10 Yamanouchi K Ikematsu Y Waki S Kida H Nishiwaki Y Gotoh K et alSolitary splenic metastasis from gastric cancer report of a case Surg Today200232(12)1081ndash4 httpdxdoiorg101007s005950200218
11 Pisanu A Ravarino A Nieddu R Uccheddu A Synchronous isolated splenicmetastasis from colon carcinoma and concomitant splenic abscess a case reportand review of the literature World J Gastroenterol 2007135516ndash20
12 Opocher E Santambrogio R Bianchi P Cioffi U Simone M Vellini S et al Isolatedsplenic metastasis from gastric carcinoma value of CEA and CA 19-9 in earlydiagnosis report of two cases Am J Clin Oncol 200023(6)579ndash80
13 Singh AK Shankar S Gervais DA Hahn PF Mueller PR Image-guidedpercutaneous splenic interventions Radiographics 201232(2)523ndash34httpdxdoiorg101148rg322115135
14 Keogan MT Freed KS Paulson EK Nelson RC Dodd LG Imaging-guided percuta-neous biopsy of focal splenic lesions update on safety and effectiveness AJR AmJ Roentgenol 1999172(4)933ndash7 httpdxdoiorg102214ajr172410587123
15 Kawasaki H Kitayama J Ishigami H Hidemura A Kaisaki S Nagawa H Soli-tary splenic metastasis from early gastric cancer report of a case Surg Today201040(1)60ndash3 httpdxdoiorg101007s00595-008-4002-5
Open AccessThis article is published Open Access at sciencedirectcom It is distributed under the IJSCR Supplemental terms and conditions whichpermits unrestricted non commercial use distribution and reproduction in any medium provided the original authors and source arecredited
Splenic metastasis from gastric adenocarcinoma A rare case
1 Introduction
2 Presentation of case
3 Discussion
4 Conclusion
Conflict of interest
Funding
Ethical approval
Author contributions
Authorship
References
CASE REPORT ndash OPEN ACCESS120 M Santos et al International Journal of Surgery Case Reports 7 (2015) 119ndash123
Fig 1 Image of CT scan showing a pulmonary nodule with 28 times 19 mm speculatedand irregular suspected of metastasis
interpreted as disseminated disease and it was proposed palliativechemotherapy
After 6 cycles of epirubicin oxaliplatin and capecitabine (EOX)which terminated on October2012 CA199 normalized and thepatient remained asymptomatic The OG decided to keep a sup-portive treatment
On April2013 the patient had another CA 199 elevation withan 18 mm splenic lesion on CT scan compatible with previouslydiagnosed metastasis
On August2013 the patient remained asymptomatic althoughthe splenic lesion grew to 25 mm (Fig 3) with no evidence of othermetastasis
The apparently indolent evolution of the disease and the goodphysiologic status of the patient promoted the OG decision to per-form splenectomy
The surgery was performed on the 21November2013 Intra-operatively it was seen a hard nodule on the inferior pole of the
spleen with extension to the hilum No other lesions were notedThe post-operative period was uneventful and the patient was dis-charged at the 4th day after surgery
The pathological examination confirmed the presence of a25 times 15 times 10 mm nodule with hilar and capsule invasion withhistological morphology of an adenocarcinoma After immuno-histochemical study and pathological comparative review of theprimary carcinoma the lesion was deemed most likely to be a gas-tric adenocarcinoma metastasis (Figs 4 and 5) There were twoother metastatic nodules with 15 and 10 mm located in the splenicparenchyma independent from the first nodule and with no cap-sule invasion
Again he was proposed chemotherapy with EOXAt present the patient is receiving chemotherapy with very
good tolerance and has no evidence of disease
3 Discussion
From the early 20th century there have been explanations stat-ing that there are obstacles preventing tumoral cells from reachingthe spleen These include the sharp angle of the splenic artery withthe celiac trunk and the rhythmic contraction of splenic sinusoidalsAs we know from present knowledge the success of metastizationseems to be much more dependent on the local microenvironmenton which the tumoral cells lodge and the interactions betweenthem9 The spleen seems to be hostile to the growing of clinicalmetastasis probably related to its immune function For 6 yearsour patient had ldquodormantrdquo cells or micrometastasis that suddenlystarted to grow To the best of our knowledge our case has the sec-ond longest interval from the primary diagnosis of gastric cancerto the diagnosis of splenic metastasis610
The usual suggested route of metastization is hematogeneousrelated to parenchymal location of the metastasis and no capsuleinvasion On our case there were two small parenchymal metasta-sis with no capsule invasion but the biggest metastasis had capsule
Fig 2 Image of PET-CT showing a splenic hot spot suspect of metastasis
CASE REPORT ndash OPEN ACCESSM Santos et al International Journal of Surgery Case Reports 7 (2015) 119ndash123 121
Fig 3 Image of CT scan showing a 25 mm splenic lesion near its inferior pole compatible with metastasis
Fig 4 HampE 40times and 100times ndash moderately differentiated adenocarcinoma infiltrating the splenic parenchyma and inducing a mild desmoplastic and inflammatory reaction
Fig 5 CK 7 and CK 20 400times ndash immunohistochemical studies for cytokeratins 7 and 20 showed expression of cytokeratin 7 and no expression of cytokeratin 20 Thisimmunoprofile is coincident with the primary gastric tumor profile suggesting the gastric origin of this metastasis
CASE REPORT ndash OPEN ACCESS122 M Santos et al International Journal of Surgery Case Reports 7 (2015) 119ndash123
invasion Despite this the hematogeneous route is the most prob-able since there were no lymph nodes involved at the primarysurgery and there was no peritoneal seeding
Some reported cases of isolated splenic metastasis seem to bepart of aggressive loco-regional advanced disease with great prob-ability of being a fully disseminated disease not recognized at thatpoint These cases are mostly seen on upper third gastric tumorslocally advanced tumors with extensive nodal involvement andinvariably short survival6
Most patients are asymptomatic The symptoms and signs mostfrequently reported are asthenia weight loss abdominal painanemia and splenomegaly4 There are cases of splenic abscess for-mation or rupture as initial presentation211
Most diagnosis are dependent on imaging Ultrasound and CTscan are the usual performed exams during follow-up wheneverindicated by symptoms or elevation of CEA and CA 19912 At someinstances there is doubt about the nature of lesions PET-CT scanmight be very useful since it has a high negative predictive valueconsidering malignant lesions and it might show other probablemetastatic spots not detected on CT scan78
A true pre-operative diagnosis of splenic metastasis can only bemade through biopsy Although it is rarely described it is consid-ered both safe and reliable when evaluating splenic lesions1314 Ourpatient was not submitted to biopsy since there was a good corre-lation between CT and PET-CT scan suspicion lesion evolution andtumoral markers The diagnosis of metastasis was highly probableWe recommend biopsy on less clear cases
On reported cases of isolated splenic metastasis as long as thepatients are fit they get treated by splenectomy with or withoutchemotherapy61215
Chemotherapy varies from neoadjuvant to adjuvant settingsmultidrug or monodrug regimens There are not consensual pro-tocols Our patient had multidrug chemotherapy with EOX whichare first line drugs on National Comprehensive Cancer Networkguidelines
Our case is remarkable because our patient had a resected pul-monary metastasis prior to the splenic metastasis diagnosis Thehigh probability of having multi-organ disseminated disease wasthe rationale for the decision to perform palliative chemother-apy and then supportive treatment only With time the patientproved he was a great candidate for surgery since no other metas-tasis grew This ldquowait-and-seerdquo approach has been defended as away of selecting patients that truly benefit from aggressive surgicaltreatment615 Overall the reported cases do not mention relevantcomplications from splenectomy in this setting
The reported overall survivals point an advantage if the metas-tasis are diagnosed within a medium to long follow-up Patientswho had long free disease survivals are also the ones with longestoverall survival610
4 Conclusion
In cases of isolated splenic metastasis from gastric adenocar-cinoma fit patients should be considered for splenectomy sincethere are reports of good patient survivals3610
Conflict of interest
None
Funding
None
Ethical approval
Written informed consent was obtained from the patient forpublication of this case report and accompanying images A copyof the written consent is available for review by the Editor-in-Chiefof this journal on request
Author contributions
Marco Santos design of article research manuscript revi-sion and approval Vilma Martins second surgeon designresearch revision and approval Filipa Moreno pathologicalreport photographs design revision and approval J Ramoacuten Viz-caiacuteno pathological report analysis revision and approval IsabelMesquita first surgeon and patient assistant conception anddesign of article consultant manuscript revisor final revision andapproval
Authorship
The authors claim full responsibility for the production ofthis article and state that they have seen and approve the finalmanuscript being submitted The authors declare their agreementregarding Publication Rules in International Journal of Surgery CaseReports
Key learning points
bull Splenic metastasis are rarebull Surgery should be considered for selected patients as a way of improving survival
References
1 Soares FA Herbst CRIG Metaacutestases esplecircnicas em neoplasias soacutelidas Acta OncolBras 19882(8)52ndash4
2 Lam KY Tang V Metastatic tumors to the spleen a 25-year clinicopatho-logic study Arch Pathol Lab Med 2000124(4)526ndash30 httpdxdoiorg1010430003-9985 124lt0526MTTTSgt20CO2
3 Compeacuterat E Bardier-Dupas A Camparo P Capron F Charlotte F Splenicmetastases clinicopathologic presentation differential diagnosis and patho-genesis Arch Pathol Lab Med 2007131(6)965ndash9 httpdxdoiorg1010431543-2165131[965SMCPDD]20CO2
4 Showalter SL Hager E Yeo CJ Metastatic disease to the pancreas and spleenSemin Oncol 200835(2)160ndash71
5 Agha-Mohammadi S Calne RY Solitary splenic metastasis case report andreview of the literature Am J Clin Oncol 200124306ndash10 httpdxdoiorg10109700000421-200106000-00020
6 Zhu Y Mou Y Ni J Zhou Y Jiang J Jiang Z et al Isolated splenic metastasesfrom gastric carcinoma a case report and literature review World J Gastroenterol201319(31)5199ndash203 httpdxdoiorg103748wjgv19i315199
7 Long NM Smith CS Causes and imaging features of false positives and falsenegatives on F-PETCT in oncologic imaging Insights Imaging 20112(6)679ndash98httpdxdoiorg101007s13244-010-0062-3
CASE REPORT ndash OPEN ACCESSM Santos et al International Journal of Surgery Case Reports 7 (2015) 119ndash123 123
8 Metser U Even-Sapir E The role of 18F-FDG PETCT in the evaluation ofsolid splenic masses Semin Ultrasound CT MRI J Nucl Med 200627(5)420ndash5
9 Chambers AF Groom AC MacDonald IC Dissemination and growthof cancer cells in metastatic sites Nat Rev Cancer 20022(8)563ndash72httpdxdoiorg101038nrc865
10 Yamanouchi K Ikematsu Y Waki S Kida H Nishiwaki Y Gotoh K et alSolitary splenic metastasis from gastric cancer report of a case Surg Today200232(12)1081ndash4 httpdxdoiorg101007s005950200218
11 Pisanu A Ravarino A Nieddu R Uccheddu A Synchronous isolated splenicmetastasis from colon carcinoma and concomitant splenic abscess a case reportand review of the literature World J Gastroenterol 2007135516ndash20
12 Opocher E Santambrogio R Bianchi P Cioffi U Simone M Vellini S et al Isolatedsplenic metastasis from gastric carcinoma value of CEA and CA 19-9 in earlydiagnosis report of two cases Am J Clin Oncol 200023(6)579ndash80
13 Singh AK Shankar S Gervais DA Hahn PF Mueller PR Image-guidedpercutaneous splenic interventions Radiographics 201232(2)523ndash34httpdxdoiorg101148rg322115135
14 Keogan MT Freed KS Paulson EK Nelson RC Dodd LG Imaging-guided percuta-neous biopsy of focal splenic lesions update on safety and effectiveness AJR AmJ Roentgenol 1999172(4)933ndash7 httpdxdoiorg102214ajr172410587123
15 Kawasaki H Kitayama J Ishigami H Hidemura A Kaisaki S Nagawa H Soli-tary splenic metastasis from early gastric cancer report of a case Surg Today201040(1)60ndash3 httpdxdoiorg101007s00595-008-4002-5
Open AccessThis article is published Open Access at sciencedirectcom It is distributed under the IJSCR Supplemental terms and conditions whichpermits unrestricted non commercial use distribution and reproduction in any medium provided the original authors and source arecredited
Splenic metastasis from gastric adenocarcinoma A rare case
1 Introduction
2 Presentation of case
3 Discussion
4 Conclusion
Conflict of interest
Funding
Ethical approval
Author contributions
Authorship
References
CASE REPORT ndash OPEN ACCESSM Santos et al International Journal of Surgery Case Reports 7 (2015) 119ndash123 121
Fig 3 Image of CT scan showing a 25 mm splenic lesion near its inferior pole compatible with metastasis
Fig 4 HampE 40times and 100times ndash moderately differentiated adenocarcinoma infiltrating the splenic parenchyma and inducing a mild desmoplastic and inflammatory reaction
Fig 5 CK 7 and CK 20 400times ndash immunohistochemical studies for cytokeratins 7 and 20 showed expression of cytokeratin 7 and no expression of cytokeratin 20 Thisimmunoprofile is coincident with the primary gastric tumor profile suggesting the gastric origin of this metastasis
CASE REPORT ndash OPEN ACCESS122 M Santos et al International Journal of Surgery Case Reports 7 (2015) 119ndash123
invasion Despite this the hematogeneous route is the most prob-able since there were no lymph nodes involved at the primarysurgery and there was no peritoneal seeding
Some reported cases of isolated splenic metastasis seem to bepart of aggressive loco-regional advanced disease with great prob-ability of being a fully disseminated disease not recognized at thatpoint These cases are mostly seen on upper third gastric tumorslocally advanced tumors with extensive nodal involvement andinvariably short survival6
Most patients are asymptomatic The symptoms and signs mostfrequently reported are asthenia weight loss abdominal painanemia and splenomegaly4 There are cases of splenic abscess for-mation or rupture as initial presentation211
Most diagnosis are dependent on imaging Ultrasound and CTscan are the usual performed exams during follow-up wheneverindicated by symptoms or elevation of CEA and CA 19912 At someinstances there is doubt about the nature of lesions PET-CT scanmight be very useful since it has a high negative predictive valueconsidering malignant lesions and it might show other probablemetastatic spots not detected on CT scan78
A true pre-operative diagnosis of splenic metastasis can only bemade through biopsy Although it is rarely described it is consid-ered both safe and reliable when evaluating splenic lesions1314 Ourpatient was not submitted to biopsy since there was a good corre-lation between CT and PET-CT scan suspicion lesion evolution andtumoral markers The diagnosis of metastasis was highly probableWe recommend biopsy on less clear cases
On reported cases of isolated splenic metastasis as long as thepatients are fit they get treated by splenectomy with or withoutchemotherapy61215
Chemotherapy varies from neoadjuvant to adjuvant settingsmultidrug or monodrug regimens There are not consensual pro-tocols Our patient had multidrug chemotherapy with EOX whichare first line drugs on National Comprehensive Cancer Networkguidelines
Our case is remarkable because our patient had a resected pul-monary metastasis prior to the splenic metastasis diagnosis Thehigh probability of having multi-organ disseminated disease wasthe rationale for the decision to perform palliative chemother-apy and then supportive treatment only With time the patientproved he was a great candidate for surgery since no other metas-tasis grew This ldquowait-and-seerdquo approach has been defended as away of selecting patients that truly benefit from aggressive surgicaltreatment615 Overall the reported cases do not mention relevantcomplications from splenectomy in this setting
The reported overall survivals point an advantage if the metas-tasis are diagnosed within a medium to long follow-up Patientswho had long free disease survivals are also the ones with longestoverall survival610
4 Conclusion
In cases of isolated splenic metastasis from gastric adenocar-cinoma fit patients should be considered for splenectomy sincethere are reports of good patient survivals3610
Conflict of interest
None
Funding
None
Ethical approval
Written informed consent was obtained from the patient forpublication of this case report and accompanying images A copyof the written consent is available for review by the Editor-in-Chiefof this journal on request
Author contributions
Marco Santos design of article research manuscript revi-sion and approval Vilma Martins second surgeon designresearch revision and approval Filipa Moreno pathologicalreport photographs design revision and approval J Ramoacuten Viz-caiacuteno pathological report analysis revision and approval IsabelMesquita first surgeon and patient assistant conception anddesign of article consultant manuscript revisor final revision andapproval
Authorship
The authors claim full responsibility for the production ofthis article and state that they have seen and approve the finalmanuscript being submitted The authors declare their agreementregarding Publication Rules in International Journal of Surgery CaseReports
Key learning points
bull Splenic metastasis are rarebull Surgery should be considered for selected patients as a way of improving survival
References
1 Soares FA Herbst CRIG Metaacutestases esplecircnicas em neoplasias soacutelidas Acta OncolBras 19882(8)52ndash4
2 Lam KY Tang V Metastatic tumors to the spleen a 25-year clinicopatho-logic study Arch Pathol Lab Med 2000124(4)526ndash30 httpdxdoiorg1010430003-9985 124lt0526MTTTSgt20CO2
3 Compeacuterat E Bardier-Dupas A Camparo P Capron F Charlotte F Splenicmetastases clinicopathologic presentation differential diagnosis and patho-genesis Arch Pathol Lab Med 2007131(6)965ndash9 httpdxdoiorg1010431543-2165131[965SMCPDD]20CO2
4 Showalter SL Hager E Yeo CJ Metastatic disease to the pancreas and spleenSemin Oncol 200835(2)160ndash71
5 Agha-Mohammadi S Calne RY Solitary splenic metastasis case report andreview of the literature Am J Clin Oncol 200124306ndash10 httpdxdoiorg10109700000421-200106000-00020
6 Zhu Y Mou Y Ni J Zhou Y Jiang J Jiang Z et al Isolated splenic metastasesfrom gastric carcinoma a case report and literature review World J Gastroenterol201319(31)5199ndash203 httpdxdoiorg103748wjgv19i315199
7 Long NM Smith CS Causes and imaging features of false positives and falsenegatives on F-PETCT in oncologic imaging Insights Imaging 20112(6)679ndash98httpdxdoiorg101007s13244-010-0062-3
CASE REPORT ndash OPEN ACCESSM Santos et al International Journal of Surgery Case Reports 7 (2015) 119ndash123 123
8 Metser U Even-Sapir E The role of 18F-FDG PETCT in the evaluation ofsolid splenic masses Semin Ultrasound CT MRI J Nucl Med 200627(5)420ndash5
9 Chambers AF Groom AC MacDonald IC Dissemination and growthof cancer cells in metastatic sites Nat Rev Cancer 20022(8)563ndash72httpdxdoiorg101038nrc865
10 Yamanouchi K Ikematsu Y Waki S Kida H Nishiwaki Y Gotoh K et alSolitary splenic metastasis from gastric cancer report of a case Surg Today200232(12)1081ndash4 httpdxdoiorg101007s005950200218
11 Pisanu A Ravarino A Nieddu R Uccheddu A Synchronous isolated splenicmetastasis from colon carcinoma and concomitant splenic abscess a case reportand review of the literature World J Gastroenterol 2007135516ndash20
12 Opocher E Santambrogio R Bianchi P Cioffi U Simone M Vellini S et al Isolatedsplenic metastasis from gastric carcinoma value of CEA and CA 19-9 in earlydiagnosis report of two cases Am J Clin Oncol 200023(6)579ndash80
13 Singh AK Shankar S Gervais DA Hahn PF Mueller PR Image-guidedpercutaneous splenic interventions Radiographics 201232(2)523ndash34httpdxdoiorg101148rg322115135
14 Keogan MT Freed KS Paulson EK Nelson RC Dodd LG Imaging-guided percuta-neous biopsy of focal splenic lesions update on safety and effectiveness AJR AmJ Roentgenol 1999172(4)933ndash7 httpdxdoiorg102214ajr172410587123
15 Kawasaki H Kitayama J Ishigami H Hidemura A Kaisaki S Nagawa H Soli-tary splenic metastasis from early gastric cancer report of a case Surg Today201040(1)60ndash3 httpdxdoiorg101007s00595-008-4002-5
Open AccessThis article is published Open Access at sciencedirectcom It is distributed under the IJSCR Supplemental terms and conditions whichpermits unrestricted non commercial use distribution and reproduction in any medium provided the original authors and source arecredited
Splenic metastasis from gastric adenocarcinoma A rare case
1 Introduction
2 Presentation of case
3 Discussion
4 Conclusion
Conflict of interest
Funding
Ethical approval
Author contributions
Authorship
References
CASE REPORT ndash OPEN ACCESS122 M Santos et al International Journal of Surgery Case Reports 7 (2015) 119ndash123
invasion Despite this the hematogeneous route is the most prob-able since there were no lymph nodes involved at the primarysurgery and there was no peritoneal seeding
Some reported cases of isolated splenic metastasis seem to bepart of aggressive loco-regional advanced disease with great prob-ability of being a fully disseminated disease not recognized at thatpoint These cases are mostly seen on upper third gastric tumorslocally advanced tumors with extensive nodal involvement andinvariably short survival6
Most patients are asymptomatic The symptoms and signs mostfrequently reported are asthenia weight loss abdominal painanemia and splenomegaly4 There are cases of splenic abscess for-mation or rupture as initial presentation211
Most diagnosis are dependent on imaging Ultrasound and CTscan are the usual performed exams during follow-up wheneverindicated by symptoms or elevation of CEA and CA 19912 At someinstances there is doubt about the nature of lesions PET-CT scanmight be very useful since it has a high negative predictive valueconsidering malignant lesions and it might show other probablemetastatic spots not detected on CT scan78
A true pre-operative diagnosis of splenic metastasis can only bemade through biopsy Although it is rarely described it is consid-ered both safe and reliable when evaluating splenic lesions1314 Ourpatient was not submitted to biopsy since there was a good corre-lation between CT and PET-CT scan suspicion lesion evolution andtumoral markers The diagnosis of metastasis was highly probableWe recommend biopsy on less clear cases
On reported cases of isolated splenic metastasis as long as thepatients are fit they get treated by splenectomy with or withoutchemotherapy61215
Chemotherapy varies from neoadjuvant to adjuvant settingsmultidrug or monodrug regimens There are not consensual pro-tocols Our patient had multidrug chemotherapy with EOX whichare first line drugs on National Comprehensive Cancer Networkguidelines
Our case is remarkable because our patient had a resected pul-monary metastasis prior to the splenic metastasis diagnosis Thehigh probability of having multi-organ disseminated disease wasthe rationale for the decision to perform palliative chemother-apy and then supportive treatment only With time the patientproved he was a great candidate for surgery since no other metas-tasis grew This ldquowait-and-seerdquo approach has been defended as away of selecting patients that truly benefit from aggressive surgicaltreatment615 Overall the reported cases do not mention relevantcomplications from splenectomy in this setting
The reported overall survivals point an advantage if the metas-tasis are diagnosed within a medium to long follow-up Patientswho had long free disease survivals are also the ones with longestoverall survival610
4 Conclusion
In cases of isolated splenic metastasis from gastric adenocar-cinoma fit patients should be considered for splenectomy sincethere are reports of good patient survivals3610
Conflict of interest
None
Funding
None
Ethical approval
Written informed consent was obtained from the patient forpublication of this case report and accompanying images A copyof the written consent is available for review by the Editor-in-Chiefof this journal on request
Author contributions
Marco Santos design of article research manuscript revi-sion and approval Vilma Martins second surgeon designresearch revision and approval Filipa Moreno pathologicalreport photographs design revision and approval J Ramoacuten Viz-caiacuteno pathological report analysis revision and approval IsabelMesquita first surgeon and patient assistant conception anddesign of article consultant manuscript revisor final revision andapproval
Authorship
The authors claim full responsibility for the production ofthis article and state that they have seen and approve the finalmanuscript being submitted The authors declare their agreementregarding Publication Rules in International Journal of Surgery CaseReports
Key learning points
bull Splenic metastasis are rarebull Surgery should be considered for selected patients as a way of improving survival
References
1 Soares FA Herbst CRIG Metaacutestases esplecircnicas em neoplasias soacutelidas Acta OncolBras 19882(8)52ndash4
2 Lam KY Tang V Metastatic tumors to the spleen a 25-year clinicopatho-logic study Arch Pathol Lab Med 2000124(4)526ndash30 httpdxdoiorg1010430003-9985 124lt0526MTTTSgt20CO2
3 Compeacuterat E Bardier-Dupas A Camparo P Capron F Charlotte F Splenicmetastases clinicopathologic presentation differential diagnosis and patho-genesis Arch Pathol Lab Med 2007131(6)965ndash9 httpdxdoiorg1010431543-2165131[965SMCPDD]20CO2
4 Showalter SL Hager E Yeo CJ Metastatic disease to the pancreas and spleenSemin Oncol 200835(2)160ndash71
5 Agha-Mohammadi S Calne RY Solitary splenic metastasis case report andreview of the literature Am J Clin Oncol 200124306ndash10 httpdxdoiorg10109700000421-200106000-00020
6 Zhu Y Mou Y Ni J Zhou Y Jiang J Jiang Z et al Isolated splenic metastasesfrom gastric carcinoma a case report and literature review World J Gastroenterol201319(31)5199ndash203 httpdxdoiorg103748wjgv19i315199
7 Long NM Smith CS Causes and imaging features of false positives and falsenegatives on F-PETCT in oncologic imaging Insights Imaging 20112(6)679ndash98httpdxdoiorg101007s13244-010-0062-3
CASE REPORT ndash OPEN ACCESSM Santos et al International Journal of Surgery Case Reports 7 (2015) 119ndash123 123
8 Metser U Even-Sapir E The role of 18F-FDG PETCT in the evaluation ofsolid splenic masses Semin Ultrasound CT MRI J Nucl Med 200627(5)420ndash5
9 Chambers AF Groom AC MacDonald IC Dissemination and growthof cancer cells in metastatic sites Nat Rev Cancer 20022(8)563ndash72httpdxdoiorg101038nrc865
10 Yamanouchi K Ikematsu Y Waki S Kida H Nishiwaki Y Gotoh K et alSolitary splenic metastasis from gastric cancer report of a case Surg Today200232(12)1081ndash4 httpdxdoiorg101007s005950200218
11 Pisanu A Ravarino A Nieddu R Uccheddu A Synchronous isolated splenicmetastasis from colon carcinoma and concomitant splenic abscess a case reportand review of the literature World J Gastroenterol 2007135516ndash20
12 Opocher E Santambrogio R Bianchi P Cioffi U Simone M Vellini S et al Isolatedsplenic metastasis from gastric carcinoma value of CEA and CA 19-9 in earlydiagnosis report of two cases Am J Clin Oncol 200023(6)579ndash80
13 Singh AK Shankar S Gervais DA Hahn PF Mueller PR Image-guidedpercutaneous splenic interventions Radiographics 201232(2)523ndash34httpdxdoiorg101148rg322115135
14 Keogan MT Freed KS Paulson EK Nelson RC Dodd LG Imaging-guided percuta-neous biopsy of focal splenic lesions update on safety and effectiveness AJR AmJ Roentgenol 1999172(4)933ndash7 httpdxdoiorg102214ajr172410587123
15 Kawasaki H Kitayama J Ishigami H Hidemura A Kaisaki S Nagawa H Soli-tary splenic metastasis from early gastric cancer report of a case Surg Today201040(1)60ndash3 httpdxdoiorg101007s00595-008-4002-5
Open AccessThis article is published Open Access at sciencedirectcom It is distributed under the IJSCR Supplemental terms and conditions whichpermits unrestricted non commercial use distribution and reproduction in any medium provided the original authors and source arecredited
Splenic metastasis from gastric adenocarcinoma A rare case
1 Introduction
2 Presentation of case
3 Discussion
4 Conclusion
Conflict of interest
Funding
Ethical approval
Author contributions
Authorship
References
CASE REPORT ndash OPEN ACCESSM Santos et al International Journal of Surgery Case Reports 7 (2015) 119ndash123 123
8 Metser U Even-Sapir E The role of 18F-FDG PETCT in the evaluation ofsolid splenic masses Semin Ultrasound CT MRI J Nucl Med 200627(5)420ndash5
9 Chambers AF Groom AC MacDonald IC Dissemination and growthof cancer cells in metastatic sites Nat Rev Cancer 20022(8)563ndash72httpdxdoiorg101038nrc865
10 Yamanouchi K Ikematsu Y Waki S Kida H Nishiwaki Y Gotoh K et alSolitary splenic metastasis from gastric cancer report of a case Surg Today200232(12)1081ndash4 httpdxdoiorg101007s005950200218
11 Pisanu A Ravarino A Nieddu R Uccheddu A Synchronous isolated splenicmetastasis from colon carcinoma and concomitant splenic abscess a case reportand review of the literature World J Gastroenterol 2007135516ndash20
12 Opocher E Santambrogio R Bianchi P Cioffi U Simone M Vellini S et al Isolatedsplenic metastasis from gastric carcinoma value of CEA and CA 19-9 in earlydiagnosis report of two cases Am J Clin Oncol 200023(6)579ndash80
13 Singh AK Shankar S Gervais DA Hahn PF Mueller PR Image-guidedpercutaneous splenic interventions Radiographics 201232(2)523ndash34httpdxdoiorg101148rg322115135
14 Keogan MT Freed KS Paulson EK Nelson RC Dodd LG Imaging-guided percuta-neous biopsy of focal splenic lesions update on safety and effectiveness AJR AmJ Roentgenol 1999172(4)933ndash7 httpdxdoiorg102214ajr172410587123
15 Kawasaki H Kitayama J Ishigami H Hidemura A Kaisaki S Nagawa H Soli-tary splenic metastasis from early gastric cancer report of a case Surg Today201040(1)60ndash3 httpdxdoiorg101007s00595-008-4002-5
Open AccessThis article is published Open Access at sciencedirectcom It is distributed under the IJSCR Supplemental terms and conditions whichpermits unrestricted non commercial use distribution and reproduction in any medium provided the original authors and source arecredited
Splenic metastasis from gastric adenocarcinoma A rare case
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